A SYSTEM TO OPTIMIZE GLUCOSE TESTS IN THE HOSPITALS OF HUILA DEPARTMENT IN COLOMBIA

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1 A SYSTEM TO OPTIMIZE GLUCOSE TESTS IN THE HOSPITALS OF HUILA DEPARTMENT IN COLOMBIA Albeiro Cortés Cabezas and José de Jesús Salgado Patrón Department of Electronic Engineering, Surcolombiana University Grupo de Tratamiento de Señales y Telecommunications-GTST Pastrana Av. Neiva Colombia albecor@usco.edu.co ABSTRACT Nowadays many health centers in the world have robust hospital information systems capable of storing and processing the collected data of all type of variables associated to the different medical and laboratory tests that are made to the users of the service. A hospital information system enables the integrity and readability of patient information to be guaranteed. In addition, it makes it possible for such information to be available at the point of care where the patient is, independently of the institution providing health services where it is attended. Unfortunately, hospitals in Huila do not yet have an adequate information system, so that old-fashioned, complex and unstructured methods are used, such as handwriting the results of tests performed in paper formats, which are then examined and analyzed by the attending physician and then make the relevant decisions. In this project, an information system was implemented to optimize the process of glucose testing (glucometry) in hospitals in Huila to improve the organization of data, making access much more comfortable. The HL7 standard set was used as a guide for good interoperability and to make the system scalable. Access can be made through a mobile application, which was developed using Android Studio or through a website. The information system allows access to the data of a specific patient and also has the option of graphing them to observe the evolution of glucose levels over time and thus provide the appropriate treatments for each case. Keywords: information system, glucose, web services, android, HL7-FHIR. 1. INTRODUCTION According to the World Health Organization, WHO, there are more than 422 million people in the world who suffer from diabetes and according to projections by 2030 this will be the seventh cause of mortality if no actions are taken to control their growth. Because of this, diabetes is considered one of the diseases to which the most attention should be paid from the point of view of the public health sector [1]. It is believed that in Colombia approximately 1,200,000 people suffer from diabetes which is equivalent to almost 2.7% of the population. In the Department of Huila 7,200 people were diagnosed with diabetes by 2013 and from all municipalities, Neiva, the capital had the highest number of people affected [2]. The therapy commonly used for treating diabetes is to perform blood glucose tests to record and monitor the evolution of blood sugar levels over time. The glucose test measures glucose concentration in the blood by means of easy-to-use sensors and is a helpful tool for people with diabetes [3]. It is necessary that this process of registration of the data be done in a constant and orderly way to have a history that describes the behavior and the evolution of that disease. Continuous monitoring of blood glucose allows for early detection and prevention of chronic complications (such as hypoglycemia and hyperglycemia), as well as adjustments to medications, diet and certain habits if necessary [4]. Normally, when a patient with diabetes is admitted in a hospital, doctor orders regular blood glucose tests (at least 7 daily) for some time, to monitor the progress and initiate appropriate treatment. Hypoglycemia is defined as an abnormally low blood glucose concentration below 70 mg/dl, and hyperglycemia is defined as an excessive amount of glucose in the blood, higher than 110 mg/dl. Through the analysis of these measurements, it is possible to choose the most adequate diet, the appropriate type of insulin and recording historical behavior. Also, doctor may decide to prescribe an outpatient treatment, avoiding the patient's hospital stress. In the case of Huila s hospitals, blood glucose tests are performed by nurses, who use generic meters to obtain the blood glucose concentration value. Then, these data are recorded on paper to be reviewed later by the specialist in charge. To diagnose or medicatea patient, physician has to check data on paper one by one to look for possible anomalies in behavior of blood glucose. This is a tedious and impractical task that sometimes leads to human errors; since some important detail can be overlooked leading to the choice of inappropriate treatment. An additional aggravating factor to consider is that the number of patients who should be tested for blood glucose is quite high. For example, from the 400 beds available at the Hospital Universitario de Neiva, 100 are for diabetic patients, which mean that at least 700 blood glucose tests should be made daily. The problem here is that Huila s hospitals do not have an adequate Hospital Information System - HIS, which allow physicians and nurses recording patient data properly in a way that minimizes the errors probability. Due to the large number of tests performed daily, the amount of paper and data is very high, which can easily lead to inaccuracies in subsequent analyzes. Additionally, physicians are deprived of the possibility of automatically generating adequate graphs where they can observe the evolution of the patient during their staying in the hospital or during previous stays, as well as, annotations to try to justify the possible causes of each particular evolution. On the other hand, the hospitals and the Secretary of Health 4182

2 need to store the data of all the patients of suitable form with the objective to use them later to obtain the statistics of the disease in the Department. This information is also valuable to other scientists who will use it as a starting point to initiate multiple investigations related to the diabetes problem in the department and the country. This article presents the design and implementation of an information system for the registration, organization and analysis of the results of blood glucose tests in Huila s hospitals. The main objective of the work is to create an HIS that allows recording the data of the patients and to record the results of the tests realized either by a doctor, a nurse or by the same patient. Data can be fed into the Hospital's local area network as well as from any remote computer or device (Smart phone or Tablet) connected to the Internet. The HIS designed follow the guidelines of the HL7 FHIR standard, the most widespread in the world which guarantees its easy interoperability with almost any other hospital information system. According to the World Health Organization - WHO, if better information is available, better decisions will be made and the population will be able to have better health. This justifies the need for more robust HISs for hospitals in Huila. As computer systems evolving, information systems for management data about health of patients were available. These information systems can also report statistics about the data obtained through the tests performed, as well as, about medicines and treatments formulated by physicians. Examples of these systems are the Care2x (Open Source Hospital Information System), first published in 2002 by Elpidio Latorilla and the Mexican Government's Information System for Hospital Management (SIGHO), which began on 2005 [ 5-7]. In the Department of Huila this technology is just beginning to be implemented. Therefore, this work can be considered as an initial contribution on this area. 2. METHODOLOGY General design of the information system Figure-1 shows the block diagram of the proposed strategy to solve the problem presented above. For its development a schedule that included the different stages of work was proposed, starting with the database, then the web application and finally the mobile application. Once the development was completed, a period of tests continued to evaluate the behavior of the entire system. HL7-FHIR standard HL7-FHIR (Health Level 7 - Fast Healthcare Interoperability Resources) is a standard that describes "resources", data formats, and electronic health records exchange (EHR) elements. The standard was created by the international health standards organization HL7. One of HL7-FHIR's objectives is to facilitate interoperability between different health care systems, so that be easy to provide healthcare information to healthcare providers and individuals through a wide variety of devices, from computers to tablets and cell phones; enabling third-party application developers to develop medical applications that can be easily integrated with existing information systems. HL7-FHIR is relatively easy to deploy, because it uses a modern web-based technology suite, including RESTful, HTML and Cascading Style Sheets (CSS) for UI integration. For data representation JSON or XML can be used and for authorization OAuth can be used [8]. Figure-1. Information system architecture.. In this paper, JSON was chosen for data representation, which means interoperability with other information systems using the same technology for exchanging EHRs will be simple and guaranteed. However, interoperability with information systems that use a different technology to represent data, such as XML or others can be achieved through a management tool for integration of multiple health information systems, such as MirthConnect [9]. It should be noted that this paper is part of a more ambitious project for the Department of Huila, which seeks to systematize the entire health system, so that interoperability between different health information systems must be guaranteed. Database server MySQL is the most popular open source database in the world, making it a reliable and secure option. It also has features such as high scalability, easy operation, high performance among others, making it the ideal choice for the needs of the information system. The database contains all the information that is stored for the application services. The tables save the user profiles and the requested information for each of them. Patient glucose information is also stored. Figure 2 shows the tables used in the database. The patient, personal and root tables contain user information depending on your profile as a patient, medical staff or system administrator respectively. The glucose table contains the parameters for storing the patient's glucose test results. According to the HL7 standard for the management of medical information, some records store the information in JSON format, allowing the data to be transmitted according to the standard. 4183

3 Web platform The web platform allows users to perform functions for handling of information recorded in the system. There are three types of users in the systems, which are defined below: Figure-2. Tables of the database. Admin user: This user has the function of registering patients and medical personnel. He can update or delete user information. Staff user: He cans view his personal information on the website, and have access to the patient's data. The platform allows him to record patient glucose measurements and view the measurement history in tabular or chart mode. Patient user: He cans view your personal information on the website. The platform allows you to record glucose measurements and view the measurement history in tabular or graphical mode. Figure-3 shows the home page that shows the web platform when accessing the system. Figure-3. Web platform home. Developments technologies For the development of the web project tools with free software license were used. Project developed usin: NetBeans IDE 8.1 (Build ) Java: 1.8.0_77; Java HotSpot (TM) 64-Bit Server VM b03 Runtime: Java (TM) SE Runtime Environment 1.8.0_77-b03. Data base: MySQL Workbench build 511 CE (64-bit) Community Database port for MySQL: 3306 Application server: Apache Tomcat Programming languages: HTML, CSS and JS: For view handling and script functions on the client side. HTML5 organizes parameters for HTML page structure tagging, CSS3 builds the page appearance for an interesting visual style and JS allows the construction of page functions on the client to avoid loading on the server. JSF and JAVA: JSF is a java application framework with which the web pages of the project are developed and deployed. The server receives client requests and performs control of views and database using java. In addition, the following tools were used: 4184

4 Primefaces: This library allows the creation of rich content for the handling of views and the functions of the platform. It is a library of components for JSF. Bootsfaces: AsPrimefaces allows managing views with JSF, this library integrates page views with visual styles similar to the bootstrap of Twitter. Font Awesome: This library contains a compilation of icons to give better visual style to the pages. Javax.mail version 1.4.7: Allows sending mail messages from the server to the users. It is used to send an to the user when requesting a password recovery. Gson version 2.6.2: Class library for JSON handling using java language. Mysql connector version : Library for controlling connections to the MySQL database from java. Mobile app GlucUp-2Date is a mobile application developed during the project, which allows users to perform operations for managing the information registered in the system. In this application only two profiles are allowed: Staff user: Through this profile the application shows all related patients or allows doing patient search. It allows to register glucose tests performed on patients and to view the history of tests carried out in table format or in graphical mode. Patient user: Through this profile the patient can view his or her personal information. The platform also allows the patient to record glucose tests and view the history in table format or in graphical mode. Figure-4 shows the start view of the GlucUp- 2Date application. For the development of this application Android Studio 2.2 (Build # AI ) and JRE: 1.8.0_76- release-b03 amd64 were used. The following tools were also used: SupportAppCompat v7: This library allows using design material and action bar through design patterns. Includes activity management to display as AppCompatDialog dialogs. Supportdesign: This is a companion library for AppCompat. Allows using special components: Navigation Drawer, Floating Action Button, Snackbars and Tabs. Supportrecyclerview: This is a companion library for AppCompat. Allows using the RecyclerView class and handle lists in recycled views. Code GSON: This is a library of Google classes for handling JSON using java. Support Support v4: This is a library for handling the APIs for server communication and exception handling. BartekscAndroidPdfViewer: This tool is used in the help section to display user manuals in the same application. PhliJayMPAndroidChart: This is a tool used in graphs creation to show the results. Bar graphs, linear and joints. Support CardView: This is a companion library for AppCompat. It is used to make use of the CardView element to create items in recyclable lists. Code-troopers Betterpickers: This library is used to create time and date selection designs. Support ConstraintLayout: This library is used to manage the Constraint Layout, a new Layout to create responsive screens for different devices. Firebase Messaging: This is a library for handling notifications using FireBase Cloud Messaging. RESULTS All software designed during the project, reports, user manuals and the mobile application installation file can be consulted and downloaded from The project folder contains the following elements: Figure-4. GlucUp-2Date starting view. Android App: Contains the project folder in Android Studio "GlucUp-2Date" and the application APK compiled "GlucUp-2Date.apk". Database: Contains the entity-relationship (EER) model "EERDatabase.mwb" and the script to create the database in MySQL "ScriptSqlDatabase.sql". JavaDoc: Contains the Javadoc of the Android application "GlucUp-2Date_JavaDoc" and the web server "JavaDoc Web Server". User Manual: Contains the user manual of the Android application and the web application "Manual_Usuario_GlucUp-2Date.pdf", "Manual_Usuario_Web.pdf". 4185

5 Web App: Contains the web server project folder "Glucometrics" and the WAR file for deployment on the Tomcat server "Glucometrias.war". Report.pdf: Contains project development information. README.md: Contains project information for Github. The information system allows patients, physicians and auxiliary staff to enter glucose test results for each patient. For each examination the status of the patient, the time, the unit of measure used (mmol/l or mg/dl) and the test result are recorded. For convenience of mobile users GlucUp-2Date allows to create alarms to remember the entry of glucose records. Alarms can be set at a specific time and repeated on different days. Consultation of data and statistics Patients and medical staff will be able to view test results in a number of ways including charts and graphs of various types. Figure-5 shows an example of how the results history is presented in tabular form for a patient. Figure-6 shows an example of how the history of one-day results in graphical mode is presented. Figure-7 shows an example of how the history of all patient outcomes in timeline mode is presented. Figure-5. Results history in table form. Figure-6. History of results of a day in graphic mode. 4186

6 Figure-7. History of a patient's results in timeline mode. Connection with other information systems The information system is enabled to communicate with any other health information system that supports the HL7-FHIR standard and package the data using the JSON standard. This can be easily achieved by establishing channels between this system and any other that meets the above requirement, using Mirth Connect or a similar tool. Systems that pack their data using XML or other technologies can also be supported by making small adaptations. 4. CONCLUSIONS It is possible to optimize the glucose testing process in hospitals in Huila with the information system implemented, saving time and making work of medical staff more easy when they choosing treatments according to the specific condition of each patient. By having graphs, tables and statistics, physicians have the possibility to evaluate the efficiency of a medication or diet assigned to a diabetic patient. They can also make adjustments if necessary. The use of information technologies should be intensified through development of projects that solve many of the problems that afflict the Colombian health system. As has been shown, the Electronic Engineering Program of the Surcolombiana University can contribute to the development of the city, the department and the country. The information system here presented ensures the integrity and readability of patient information and makes it possible for information to be available anywhere, regardless of the institution providing health services. The execution of this project is expected to mark the way forward in the department and in the country in terms of the use of computer technologies as an immediate solution to many difficulties of the hospital centers. We hope to generate the basis for future projects that involve a full integration of the different areas of the hospital into robust, effective and reliable hospital information systems. ACKNOWLEDGEMENTS This work was funded by the Surcolombiana University in Colombia through the project with code GI2016ING05. REFERENCES [1] World Health Organization. Diabetes. [On-line]. Descriptive notes, [Accessed October 12, 2016].Available in: [ [2] La Nación. Diabetes, enfermedad de altos costos sociales. [On-line]. La Nación, March 30, [Accessed October 12, 2016]. Available in: [ m/ diabetes-enfermedad-de-altos-costossociales]. [3] Donner, T. W.; Flammer, K. M. Tratamiento de la diabetes en el hospital. Clínicas Médicas de Norteamérica. ELSEVIER Saunders, 2008, 92(1): [4] San Vicente Fundación. Guía para el automonitoreo de la glucemia. [On-line]. Vida sana, cuidados del paciente, [Accessed June 19, 2016]. Available in: [ [5] Care2x Team. The open source hospital information system. [On-line]. About Care2x, [Consultado el 20 de octubre de 2016]. Available in: [ 4187

7 [6] INTRAMED. Sistemas de información hospitalaria. [On-line]. Informatización hospitalaria, [AccessedOctober20, 2016]. Available in: [ ID=44061]. [7] Gobierno Del Estado De Sonora. Sigho. [On-line]. SIES Sistema de Información Estratégica en Salud, [AccessedOctober20, 2016]. Available in: [ [8] OAuth. [AccessedNovember 20, 2016]Available in: [ [9] MirthConnect. [AccessedNovember20, 2016]Available in: [ 4188